Vertebroplastia percutánea guiada por tomografía para el manejo del dolor en pacientes con fractura del cuerpo vertebral / CT-guided Vertebroplasty for Painful Vertebral Fractures

Objetivo Describir la técnica y resultados en cuanto a la mejoría del dolor y complicaciones al realizar este procedimiento mediante guía por tomografía computada. Materiales y Métodos Estudio observacional descriptivo de una serie de 108 pacientes a quienes se les realizó vertebroplastia percutánea guiada por tomografía computada realizadas en dos hospitales universitarios, entre mayo 2007 y mayo 2017. Todos los procedimientos se realizaron de forma ambulatoria con anestesia local y se valoró el dolor mediante la escala visual análoga. Resultados Se realizaron 125 vertebroplastias, en el 87,9% de los pacientes (n = 95) se realizó el procedimiento en un cuerpo vertebral, en el 8,3% (n = 9) y 3,7% (n = 4) de los pacientes se cementaron 2 y 3 vertebras respectivamente. El rango de dolor según la escala visual análoga (EVA) previo al tratamiento varió entre 5 y 10, donde un 94% (n = 102) de los pacientes manifestaban una intensidad 10/10. En el postratamiento el rango de dolor varió entre 0a7dondeel 98% de la población reportó un valor menor o igual a 3. Se presentaron 3 complicaciones: tromboembolismo pulmonar por metil-metacrilato, extravasación al plexo de Batson y extravasación al espacio interdiscal, cada una en tres pacientes diferentes. Conclusión La vertebroplastia percutánea guiada por TC ofrece una indiscutible mejora inmediata del dolor en pacientes con fractura de uno o más cuerpos vertebrales, con una baja tasa de complicaciones.

Objetive Describe the technique, results in terms of pain improvement and complications to perform this procedure by computed tomography. Materials and Methods A descriptive observational study of a 108 cases series of percutaneous vertebroplasty guided by computed tomography performed in two university hospitals between May 2007 and May 2017. All procedures were performed with local anesthesia on an outpatient basis, pain was assessed by means of the Visual analogue scale (VAS). Results A total of 125vertebroplasties were performed. In 87.9% (n = 95) of the patients, the procedure was performed in one vertebral body, in 8.3% (n = 9) and 3.7% (n = 4) of the patientshad two or three vertebrae cemented respectively. The range of pain according to VAS prior to treatment varied between 5 and 10, where 94% (n = 102) of the patients manifested a 10/10 intensity; after treatment, the range of pain varied between 0 to 7 where 98% of the population reported a value less than or equal to 3. Three complications were reported, one pulmonary thromboembolism due to methylmethacrylate, one extravasation in to the Batson plexus and one extravasation of cement to the interdiscal space. Conclusion CT-guided percutaneous vertebroplasty offers an undeniable immediate improvement of pain in patients with fracture of one or more vertebral bodies, with a low rate of complications.

Un recorrido por la pared abdominal: evaluación de las hernias por tomografía computada multidetector / A tour of the abdominal wall: assessment of hernias by multidetector computed tomography

Si bien el diagnóstico de hernias de la pared abdominal es clínico y el estudio más indicado es la ecografía, en una gran cantidad de casos es difícil su evaluación o no se sospecha su presencia debido al biotipo del paciente, la ausencia de síntomas, la aparición de complicaciones o corresponde a algún tipo de hernia poco frecuente. Además, la debilidad de la pared abdominal generada por una cirugía predispone a la eventración de órganos, a veces poco habituales, como el hígado, la vejiga o el apéndice. La utilización de la tomografía computada multidetector (TCMD) brinda grandes ventajas cuando resulta dificultoso establecer el diagnóstico por otros métodos. También puede ser un hallazgo incidental a tener en cuenta por sus posibles complicaciones futuras. En el presente trabajo describimos los principales hallazgos por TCMD de las hernias y eventraciones de la pared abdominal (como la umbilical, epigástrica, hipogástrica, inguinal, de Spiegel, lumbar, obturatriz, intercostal e incisional) y su contenido.

Although the diagnosis of abdominal wall hernias is clinical, and the most appropriate study is ultrasound, in a lot of cases they are difficult to evaluate, or their presence is not suspected because of the biotype of the patient, the absence of symptoms, the presence of complications, or the appearance of rare hernias. Surgery weakness generated in the wall leads to organ hernia, sometimes unusual, as in the liver, bladder, or appendix. The use of multidetector computed tomography (MDCT) is a great advantage in these situations where the diagnosis can be difficult to determine with other methods. It also can be an incidental finding to consider eventual complications. In this paper, the main MDCT findings in abdominal wall hernias are described, including umbilical, epigastric, hypogastric, inguinal, Spiegel, lumbar, obturator, intercostal, and incisional, as well as their content.

Cefalea... ¿y algo más?: Neuroimágenes en el estudio de la cefalea / Headache and something else? Neuroimaging in the study of headaches

Se revisa la iconografía de los hallazgos por tomografía computada (TC) y resonancia magnética (RM) de la cefalea, según nuestra experiencia. De acuerdo con la base MESH, esta entidad se define como un dolor craneano, que puede ser de ocurrencia benigna o la manifestación de una amplia gama de desórdenes. Las cefaleas se clasifican por su evolución temporal (aguda o crónica), presentación (en estallido, gravativa, etc.) o coexistencia de síntomas asociados, como auras, convulsiones o déficits focales. También se dividen en primarias o secundarias, según la existencia o no de una patología subyacente. Las primarias pueden tener manifestaciones clínicas definidas, pero en las secundarias ciertos signos y síntomas deben alertar sobre la presencia de una patología estructural. En este caso, las neuroimágenes tienen un rol esencial al detectar las causantes del cuadro. Nuestros hallazgos correspondieron a cefaleas primarias (p. ej: infarto migrañoso) y a etiologías orgánicas, entre las que se destacaron causas vasculares, como patología venosa (trombosis), vasoespasmo y leucoencefalopatía posterior reversible; hemorragias intraparen-quimatosas y extraaxiales; cefaleas postraumáticas y posquirúrgicas; y causas infecciosas y tumorales (apoplejía hipofisaria e hipertensión endocraneana). Además, hubo malformaciones (Arnold-Chiari, p.ej.) y otras como hipotensión endocraneana. En algunos casos inicialmente se realizó una TC y luego una RM, mientras que en otros la RM fue el método de elección. Las neuroimágenes facilitan el estudio de la cefalea, caracterizando la afección en primaria o secundaria. En el segundo caso permiten, a su vez, clasificar los hallazgos

A review is presented of the radiological findings (computed tomography -CT- and magnetic resonance imaging -MRI-) of headache, according to our experience. According to MESH database this entity is a skull based pain that can have a benign cause or be an expression of a wide spectrum of disorders. Headaches can be classified according to their temporal evolution (acute or chronic), presentation (blow up, aura, rapidly evolutionary, etc.), or according to associated symptoms, such as seizures or focal deficits. They could also be classified into primary or secondary, depending on the presence or absence of demonstrable disease. The primary headaches can have known symptoms (i.e. migraine), but in secondary ones certain symptoms and signs should alert on the existence of structural disease. At this point imaging methods have an outstanding role, as they allow detecting and identifying structural causes in patients with headache. Our findings corresponded to primary headaches (i.e.: migraine infarction) and organic aetiologies, such as vascular causes (venous thrombosis, vasospasm and posterior reversible leukoencephalopathy); intracerebral and extra-axial haemorrhage; post-surgical and post- traumatic headaches; and those due to infections and tumours (pituitary apoplexy or intracranial hypertension). Malformations, such as Arnold-Chiari's, and intracranial hypotension have also been found. In some cases a CT is initially performed and then an MR, whilst in others MR is the method of choice. Neuroimaging facilitates the study of headache, helping to characterise them into primary or secondary. In the latter case, the imaging also enables the findings to be classified

Embolización portal hepática preoperatoria con lipiodol y gelatina absorbible / Preoperative hepatic portal vein embolisation with lipiodol and absorbable gelatin

Objetivo: Describir los resultados de la embolización portal hepática (EPH) preoperatoria con lipiodol y gelatina absorbible para generar hipertrofia hepática y permitir la hepatectomía derecha en pacientes con tumores hepáticos e hígado remanente futuro insuficiente. Materiales y métodos: Entre marzo de 2002 y abril de 2014, en 18 pacientes candidatos a hepatectomía derecha se realizó EPH con lipiodol y esponja de gelatina absorbible mezclada con contraste yodado. La estimación de los volúmenes hepáticos preembolización se hizo por tomografía computada con contraste endovenoso. Los pacientes fueron abordados mediante punción percutánea bajo guía ecográfica, seguida de angiografía. El control de la hipertrofia con estimación del volumen se realizó a la cuarta semana posembolización y el seguimiento se llevó a cabo ambulatoriamente o mediante historia clínica. Resultados: La mediana de edad fue de 58 años (relación hombre/mujer de 1:0,8) y el volumen hepático total estimado (mediana) de 1587,75 cm³. La estimación previa del volumen hepático y su relación con la porción futura remanente pre-EPH fue de 19,9%, mientras que el promedio absoluto de crecimiento del parénquima hepático remanente futuro pos-EPH se encontró entre los 306,2 y 475,2 cm³, con un 43,5% de aumento. La mediana de incremento de la relación volumen hepático total y la porción remanente pos-EPH fue de 8,5% (p< 0,001). Como complicaciones, se registró un hematoma y una necrosis aséptica. Conclusión: La EPH con lipiodol y esponja de gelatina absorbible es un procedimiento seguro y efectivo, que surge como alternativa a otros materiales de embolización.

Objective: To evaluate outcomes of preoperative hepatic portal vein embolisation with lipiodol and absorbable gelatin in order to generate liver hypertrophy and enable right hepatectomy in selected patients with liver tumours and future insufficient residual liver. Materials and methods: Portal vein embolisation (PVE) with lipiodol and absorbable gelatin sponge mixed with iodine based contrast was performed in 18 patient candidates for right hepatectomy between March 2002 and April 2014. The preembolisation liver volume evaluations were performed by computed tomography with intravenous contrast. Patients underwent an ultrasound-guided percutaneous puncture, followed by angiography. The controls of hypertrophy and volume estimation were performed in the 4 th week after portal embolisation. The patients were followed-up on an outpatient basis or by using their medical records. Results: The median age was 58 years, with a 1:0.8 male: female ratio. The total estimated liver volume, excluding the tumour, of all patients evaluated prior to surgery was 1587.75 cm³ (median). The previous estimated liver volume and its relation to the future remaining portion before PVE was 19.9%. The absolute median growth of future residual liver parenchyma post-PVE was 306.2 to 475.2 cm³, being an increase of 43.5%, and the mean growth of liver volume and remaining portion ratio post-PVE was 8.5% (P<.001). Complications were one haematoma and one aseptic necrosis. Conclusión: The selection of patients is of paramount importance, and PVE with lipiodol and absorbable gelatin in our environment is a safe and effective procedure.

Patrones imagenológicos por TCMD del linfoma renal / CTMD imaging patterns of renal lymphoma

El linfoma es una neoplasia que puede comprometer con frecuencia al sistema genitourinario,en especial a los riñones. En su mayoría son secundarios a una afectación sistémica. Describimos los hallazgos imagenológicos de los distintos patrones de presentación del linfoma renal...

Hemorragia abdominal espontánea: evaluación por imágenes / Abdominal hemorrhage spontaneous: imaging evaluation

Se define como hemorragia intraabdominal espontánea a aquella que no es de causa traumática. Su presentación clínica es inespecífica, por lo que el diagnóstico suele realizarse en base a los hallazgos imagenológicos. El estudio de imágenes cumple tres funciones básicas: realizar el diagnóstico al detectar la presencia de sangre intraabdominal, localizar el origen del sangrado y determinar la presencia o no de extravasación arterial activa. Las causas del hemoperitoneo no traumático son diversas y se pueden clasificar, según el órgano de origen, en hepáticas, esplénicas, pancreáticas, adrenales, renales, gineco-obstétricas, vasculares y de partes blandas (peritoneales y musculares)

It defines spontaneous abdominal hemorrhage that is not traumatic. Its clinical presentation is nonspecific and usually not suspected by the emergency physician, so the diagnosis is usually made based on imaging findings. The study of images serves three basic functions, which are to perform the diagnosis by detecting the presence of blood intraabdominal, locating the source of bleeding and determining the presence or absence of active arterial extravasation. The causes of non traumatic hemoperitoneum are diverse and can be classified according to the organ of origin in liver, spleen, pancreas, adrenal, kidney, obstetric-gynecology, vascular and soft tissue (peritoneal and muscular)

Hemorragia abdominal espontánea: evaluación por imágenes

Se define como hemorragia intraabdominal espontánea a aquella que no es de causa traumática. Su presentación clínica es inespecífica, por lo que el diagnóstico suele realizarse en base a los hallazgos imagenológicos. El estudio de imágenes cumple tres funciones básicas: realizar el diagnóstico al detectar la presencia de sangre intraabdominal, localizar el origen del sangrado y determinar la presencia o no de extravasación arterial activa. Las causas del hemoperitoneo no traumático son diversas y se pueden clasificar, según el órgano de origen, en hepáticas, esplénicas, pancreáticas, adrenales, renales, gineco-obstétricas, vasculares y de partes blandas (peritoneales y musculares).(AU)

It defines spontaneous abdominal hemorrhage that is not traumatic. Its clinical presentation is nonspecific and usually not suspected by the emergency physician, so the diagnosis is usually made based on imaging findings. The study of images serves three basic functions, which are to perform the diagnosis by detecting the presence of blood intraabdominal, locating the source of bleeding and determining the presence or absence of active arterial extravasation. The causes of non traumatic hemoperitoneum are diverse and can be classified according to the organ of origin in liver, spleen, pancreas, adrenal, kidney, obstetric-gynecology, vascular and soft tissue (peritoneal and muscular).(AU)

No nos olvidemos del bazo: el órgano huérfano / Do not forget the spleen: The orphan organ

Si bien cumple una función esencial en procesos como la filtración sanguínea y respuesta inmunitaria, el bazo es el órgano abdominal olvidado o huérfano, ya que ningún especialista (incluyendo a los radiólogos) le presta atención. No obstante, este puede verse afectado por una gran cantidad de patologías benignas y malignas, cuyas características en imágenes es importante conocer para lograr un correcto diagnóstico. En el presente artículo realizamos un ensayo iconográfico sobre las distintas entidades que pueden comprometerlo.

Even when the spleen plays a key role in processes such as blood filtration and immune response, it is the abdominal organ forgotten or orphan. The spleen can be affected by much benign and malignant disease, and is important to know the characteristics images of them to achieve a correct diagnosis. In this iconographic assay we show images of several of these diseases.

No nos olvidemos del bazo: el órgano huérfano

Si bien cumple una función esencial en procesos como la filtración sanguínea y respuesta inmunitaria, el bazo es el órgano abdominal olvidado o huérfano, ya que ningún especialista (incluyendo a los radiólogos) le presta atención. No obstante, este puede verse afectado por una gran cantidad de patologías benignas y malignas, cuyas características en imágenes es importante conocer para lograr un correcto diagnóstico. En el presente artículo realizamos un ensayo iconográfico sobre las distintas entidades que pueden comprometerlo.(AU)

Even when the spleen plays a key role in processes such as blood filtration and immune response, it is the abdominal organ forgotten or orphan. The spleen can be affected by much benign and malignant disease, and is important to know the characteristics images of them to achieve a correct diagnosis. In this iconographic assay we show images of several of these diseases.(AU)

[Ectopic junctional tachycardia of the neonate]. / Tachycardie jonctionnelle ectopique du nouveau-né. A propos de 2 cas.

Congenital ectopic junctional tachycardia (EJT) is a rare arrhythmia presenting in the first 6 months of life. It is often resistant to antiarrhythmic drugs and its poor prognosis (35% mortality) explains its often complex management. The authors report two cases which illustrate its unpredictability with a potential to degenerate to serious ventricular arrhythmias. The possibility of progression to atrioventricular block, increased by antiarrhythmic therapy, may lead to implantation of a cardiac pacemaker. The poor outcome of the two babies underlines the severity of these arrhythmias.

[Ebstein's anomaly]. / Anomalie d'Ebstein.

Since Ebstein's first description in 1866 and the first surgical attempts at treatment in the 1950's, the natural history of this condition remains obscure. The anatomical description contrasts with the clinical and prognostic variability of this malformation. The form observed in the foetal or prenatal periods has a very different prognosis to that observed in adults. The risk factors are not the same even though the anatomical entity is comparable. The difficulty in managing these patients is due to the problems of diagnosis and determination of these prognostic factors. Advances in echocardiography, the key investigation which facilitates diagnosis, and in surgical and ablation techniques, have improved our understanding of this condition and its prognosis.

[Outcome of operated Fallot's tetralogy]. / Devenir des tétralogies de Fallot opérées.

Fifty years after the beginning of cardiac surgery, a large percentage of operated congenital heart disease patients attain adulthood. The tetralogy of Fallot is one of the malformations in which the natural outcome was unfortunately nearly fatal in the long-term. Open heart surgery has radically transformed the prognosis of this, the most common of all cyanotic congenital cardiac malformations. Nowadays, most operated patients lead normal professional and family lives. Lonf-term survival after correction is between 90-95% after 30-35 years. Although surgical repair is satisfactory, the operated heart is not anatomically normal. The patients have a variable degree of devalvulation of the pulmonary outflow tract, a scar on the right ventricle, a patch repairing the ventricular septal defect and scars on the atrium (cannulation for cardiopulmonary bypass). These sequellae expose the patients to a number of complications, notably arrhythmic and sometimes haemodynamic, affecting the right ventricle. The late mortality rate varies from 5 to 13% in the literature. The main causes of death are sudden death and reoperation. Sudden death is the most severe long-term complication but it is uncommon, affecting less than 5% of the population. It is mainly due to ventricular arrhythmias. Certain predisposing factors should be identified during long-term follow-up, among them the presence of haemodynamic abnormalities: systolic overload (residual pulmonary stenosis) or diastolic overload of the right ventricle (pulmonary regurgitation), infundibular aneurysm, right ventricular dysfunction. It would appear to be important to prevent pulmonary regurgitation by preserving the pulmonary valve even if it means persistence of a mild transvalvular pressure gradient. When pulmonary regurgitation is inevitable, follow-up is essential to evaluate the timing of valvulation of the pulmonary orifice. Despite these different complications which must be understood for proper follow-up of these patients, the long-term outcome of operated tetralogy of Fallot remains very good.

[Placement of an implantable defibrillator via the endocavitary route in a patient presenting with a univentricular heart and a Glenn anastomosis]. / Pose d'un défibrillateur implantable par voie endocavitaire chez une patiente présentant un coeur univentriculaire et une anastomose de Glenn.

We report the observation of a female 45 year old patient presenting with a post-surgery complex congenital cardiopathy, associated with serious ventricular rhythm disorders necessitating the placement of an implantable defibrillator. The palliative surgery performed (cavo-pulmonary Glenn anastomosis) does not allow the usual access to the right ventricle via the superior vena cava. The different possibilities for defibrillator implantation are discussed. These include associating a surgical approach to introduce the bipolar probe with subcutaneous tunnelling to connect the probe to the box.

Comparison of chronic biventricular pacing between epicardial and endocardial left ventricular stimulation using Doppler tissue imaging in patients with heart failure.

In patients with a wide QRS, drug-resistant heart failure, and a coronary sinus that is unsuitable for transvenous biventricular pacing (BVP), a transseptal approach from the right to left atrium can allow endocardial left ventricular (LV) pacing (with permanent anticoagulant therapy) instead of epicardial pacing via the coronary sinus branches. We sought to compare the effects of endocardial pacing with those of epicardial LV pacing on regional LV electromechanical delay (EMD) and contractility. Twenty-three patients (68 +/- 8 years) with severe heart failure and QRS > or =130 ms received a pacemaker for BVP. Fifteen patients underwent epicardial LV pacing, and 8 underwent endocardial LV pacing because of an unsuitable coronary sinus. All LV leads were placed at the anterolateral LV wall. Six months after implant, echocardiography and Doppler tissue imaging were performed. LV wall velocities and regional EMDs (time interval between the onset of the QRS and local ventricular systolic motion) were calculated for the 4 LV walls and compared for each patient between right ventricular (RV) and BVP. The amplitude of regional LV contractility was also assessed. Epicardial BVP reduced the septal wall EMD by 11% versus RV pacing (p = 0.05) and the lateral wall EMD by 41% versus RV pacing (p <0.01). With endocardial BVP, the septal and lateral EMDs were 21.3% and 54%, respectively (p <0.01, compared with epicardial BVP). The mitral time-velocity integral increased by 40% with endocardial BVP versus 2% with epicardial BVP (p <0.01). The amplitude of the lateral LV wall systolic motion increased by 14% with epicardial BVP versus 31% with endocardial BVP (p = 0.01). This resulted in a LV shortening fraction increase of 25% in patients with endocardial BVP (p = 0.05). However, all patients were clinically improved at the end of follow-up. Thus, in heart failure patients with BVP, endocardial BVP provides more homogenous intraventricular resynchronization than epicardial BVP and is associated with better LV filling and systolic performance.

[Significance of exercise induced ST elevation in patient without a history of previous myocardial infarct]. / Signification d'une élévation du segment ST liée à l'effort chez des patients sans antécédent d'infarctus.

UNLABELLED: Between 1980 and 1995, we observed twenty-five patients (22 males, 3 females) at the mean age of 50.6 +/- 13 years, without previous myocardial infarction who presented exercise induced ST elevation on a bicycle stress test. METHODS: Significant ST elevation was defined as a > or = 1 mm change present in > or = 1 lead measured 0.08 sec after the J point and in 3 consecutive beats. All patients have undergone coronary angiography in the days following the exercise test. RESULTS: Most of patients (56%) presented a history of typical angina that was either purely exertional (8 pts) or also occurred at rest (6 pts). Others (36%) had non typical angina or no angina (8%); 78% of pts were smokers. Sixteen patients (group I) had ST elevation during exercise (exercise duration: 7.6 +/- 4 min; peak heart rate: 135.5 +/- 29 batt/min; ST = 3.5 +/- 1.5 mm) and nine (group II) during the recovery phase (exercise duration 16.3 +/- 1.6 min; p < 0.05; peak heart rate 168 +/- 22 batt/min; p < 0.05; ST: 5.8 +/- 3 mm; p < 0.05). In group I, 1 patient had no vessel disease, 12 had one vessel disease, 3 had multivessel disease with 6 cases of hypersevere coronary stenose (> 90%). In group II, 4 patients had normal coronary arteries, there was one vessel coronary artery disease in 4 patients and multivessel in one subject, without hypersevere coronary stenosis. Correlation between anatomic location of stenosis and electrocardiographic ST elevation was excellent, particularly in case of single vessel disease (100%). All patients underwent one or more new exercise tests after therapeutic intervention (surgery n = 3; angioplasty n = 7; medical treatment n = 15), only 2 patients had persistent exercise induced ST elevation. During follow-up (5 +/- 3 years), 3 patients died (2 cardiac deaths) and 3 had recurrent angina controlled by new treatment. CONCLUSION: Exercise-induced ST elevation is a rare phenomenon in patients without prior myocardial infarction. When occurring purely during exercise, coronary lesions are frequent and often servere, in the other hand ST elevation of the recovery phase is frequently associate with normal arteries or less severe lesions. In most cases, revascularisation or medical therapy can abolish clinical and electrocardiographic abnormalities.